Ankle Joint Arthritis

Arthritis means joint inflammation, and when people talk about ankle arthritis, there are two distinct joints that are often grouped together – the ankle joint proper between the talus, fibula and tibia (shin), and the subtalar joint between the talus and calcaneus (heel bone). Sub-talar arthritis is dealt with in another section on this site.The cause of the characteristic pain, joint stiffness and swelling is loss of smooth articular cartilage surfaces. This tends to be a chronic condition with insidious onset, and unlike other areas of the body, trauma at some point in the past is a common cause. The ankle can also be affected by any of the inflammatory arthritides, but less commonly simple wear and tear osteoarthritis. There is an increased likelihood of developing ankle arthritis in those who have been involved in very strenuous sports or occupations, however, there is usually still a particular trauma or injury that started the process.

• Will my arthritis get better?
  There is nothing that will reverse the process, and most patients show a slow progression of disease and worsening of symptoms. This does not always translate into a need for intervention – as the ankle becomes more stiff, in some patients the pain can lessen. If the symptoms you are experiencing are not impacting on your quality of life, you do not require surgery. There may still be treatments available that can slow the progression of your arthritis, so it is still worthwhile discussing this with your local doctor on your next visit.
• Why am I walking differently?
  This is due to two factors – pain and stiffness. When you experience pain walking, your brain will automatically alter how you walk to be as painless as possible – this is called a pain avoiding or antalgic gait. You will try and spend as little time as you can with your full body weight on the affected side, and will often shorten your stride length. When the ankle joint becomes stiff, you lose the ability to plantar and dorsiflex the foot – in particular the ability to bend the ankle up (dorsiflexion) becomes limited. You notice this most when you need to squat, go down stairs or walk up and down hills. You can compensate a little by bending your hip and knee more, but this also makes your leg functionally shorter, and takes more energy.
• What symptoms will I have if I am developing ankle arthritis?
  Pain and swelling of the ankle joint are common, with stiffness and globally reduced range of motion. Joint deformity is a very late finding, and implies severe loss of cartilage and erosion of bone.
• How quickly will my arthritis progress?
  This is difficult to predict, as there is much variation from patient to patient. Inflammatory arthritis, including those due to infection, will tend to progress more quickly than post-traumatic arthritis.
• How can I find out if I have ankle joint arthritis?
  If you suspect you have a problem with your ankle, seek review with your local doctor. Diagnosis involves taking a detailed history and a thorough clinical examination, and where suspicion is high, performing imaging of the joint with plain X-rays. Sometimes a CT scan will also be ordered to give a 3D appreciation of the joint involvement and aid in surgical decision making. An injection of cortisone (a corticosteroid) with local anaesthetic is often used as both initial treatment and to aid in diagnosis. When injected into the ankle joint, the anaesthetic component should completely resolve the pain, though only for a few hours. The steroid will help to decrease inflammation over the following few months. If there is no improvement in pain with the injection, your problem may be in another joint.
• What non-surgical treatments are available?
  As with all arthritic joints, there are a number of simple measures that can be trailed to help cope with the symptoms. These include:

  • weight loss = even small losses decrease the load placed on this small joint.
  • activity modification = avoiding those activities that cause pain.
  • regular low impact exercise = maintain the range of motion in the joint without causing excessive load bearing on the joint.
  • physiotherapy = can help by tailoring an exercise program to suit your needs.
  • dietary supplements = there is no clear role for supplements in ankle arthritis.
  • simple analgesics such as paracetamol and over-the-counter anti-inflammatory medications like ibuprofen and voltaren can help with pain control.
  • splints and braces can be used to reduce motion in the ankle further in order to alleviate pain.
  • podiatry = a podiatrist can help in those who have foot alignment problems that can be improved with orthotics.
• What surgical treatment options are available?
  In those with early or focal disease, particularly younger patients who want to maintain joint movement, an arthroscopy may be indicated. In this operation, as in the knee, a camera and specialised instruments are inserted into the ankle, allowing your surgeon to treat any areas that are diseased. Nothing can be done to reverse the arthritis, and efforts to ‘clean up’ a joint by removing scar tissue, smoothing rough cartilage and removing loose fragments will increase movement and decrease pain in the short term, but usually lead to worsening of the arthritis in the longer term. Despite this, it remains a valid option in those wishing to delay more aggressive surgical solutions and maintain joint motion.

  The gold standard treatment for advanced ankle arthritis remains joint fusion. In this operation, the disease cartilage surfaces are removed and the exposed bony surfaces joined together under compression using plates and screws. When these bones join together, there is no longer any movement at the site and the pain resolves. For those with low demand for the joint and who would like to preserve ankle joint motion, ankle replacements are available. The results of these are not as reliable as for hips and knees, and those who are suitable for the operation form only a few percent of those patients with ankle arthritis. Dr Host will discuss with you which option is best based on your disease and lifestyle.

• Will I be able to do my usual activity after fusion surgery?
  Though there is loss of movement at the ankle joint with a successful fusion, the other joints in your foot are able to compensate a little. You will lose more of the ability to bend your foot up and down (flexion/extension) than you will lose the ability to move your foot in and out (inversion/eversion). Most people find that by removing the pain their ability to perform daily tasks increases, but at the cost of flexibility. You will have an altered gait, and it can take more energy to mobilise, which can lead to early fatigue. A fused ankle will make certain activities impossible, such as squatting, but this can usually be lived around. Dr Host will discuss with you the pros and cons of such a procedure with you prior to any surgical decision being made.
• How long will I need to be off my leg after fusion surgery?
  As fusion surgery involves joining bones together, it can be considered much like a fracture. It will take 6 weeks for the bones to unite to the point of allowing some movement of the remaining foot, and 12 weeks before you can bear weight on the leg. Following surgery you will be treated in a plaster cast for 6 weeks. This will be changed to a CAM boot at the 6 week mark, and you will need to remain non weight bearing in that for a further 6 weeks. During the 6-12 week period, you will be allowed to remove the boot to begin gentle movements of the remaining joints of the foot.

• What should I be concerned about following surgery?
  If you have any of the following signs or symptoms, please contact Dr Host or your local GP for review:

  • Increased redness, heat or swelling around your wounds.
  • Raised temperature/fever.
  • Persistent ooze from your wounds.
  • Calf pain or swelling.
  • Chest pain, chest tightness, shortness of breath or a very rapid breathing rate.